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STATE OF CALIFOnRA WATER RESOURCES CONTOL BOARD <br /> FORMW:: UNDERGROUND STORAGE TANK PROGRAM "m <br /> �o z <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION , l o <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE I".R%' <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION 7 PERMANENT SITE ~ <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE (p` W <br /> I. FACILITY/SITE INFORMATION &ADDRESS - (MUST BE COMPLETED) pop <br /> FACILITY SITE NAME CARE OF ADDRESS INFORMATION <br /> PSLwc v�o <br /> ADDRESS . NEAREST CROSS ST EET ✓e,tooJiwte ❑ PARTNERSHIP ❑ STATE AGENCY <br /> S �\;� ❑ CORPORATION F1DCAL AGENCY ❑ FEDERAL AGENCY <br /> ,.l I ❑ INDIVIDUAL [] COUN AENCYAGENCY <br /> CITY NAME STATE ZIP CODE SITE PHONE#,WITH AREA CODE <br /> err, CA S ZO Z_ rkl . <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR '714 PROCESSOR -/',B ox if INDIAN EPA ID n #of TANK's <br /> ❑ 1 GAS STATION ❑ 3 FARM ❑ 5 OTHEfl TRESTYANDS ATION o ❑ AT THIS SITERESERV" <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE#WITH AREA CODE <br /> NIGHTS: NAME(LAST.FIRST) PHONE N WITH AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE 0 WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box Io,,d,cale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY E FEDERALAGENCY <br /> E INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE#.WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to incloale ❑ PARTNERSHIP ❑ STATEAGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTYAGENCY <br /> CITY NAME STATE ZIP CODE PHONE#,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ III.❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED S SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY# JURISDICTION If AGENCY# FACILITY ID# #of TANKS at SITE <br /> m = = lololgd = <br /> CURRENT LOCAL AGENCY FACILITY ID# APPROVED BY NAME PHONE#WITH AREA CODE <br /> PERMIT NUMBER PERMIT APPROVALAATE PERMIT EXPIRATION DATE <br /> LCHECKL# <br /> CODE CENSUS TRACT# SUPERVISOR-DISTRICT CODE BUSINES,PSN FILED NO ❑ D T �^i d c7 CSIPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT# BY: <br /> as <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> ORM A(3-2-88) <br /> DATA PROCESSING COPY <br />